Provider Demographics
NPI:1972553204
Name:NORTHWEST ALABAMA CANCER CENTER RADIOLOGICAL SERVICES INC
Entity type:Organization
Organization Name:NORTHWEST ALABAMA CANCER CENTER RADIOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-764-4200
Mailing Address - Street 1:101 DR W H BLAKE JR DR
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2152
Mailing Address - Country:US
Mailing Address - Phone:256-381-1001
Mailing Address - Fax:256-381-3604
Practice Address - Street 1:302 W DR HICKS BLVD
Practice Address - Street 2:STE. B
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-6160
Practice Address - Country:US
Practice Address - Phone:256-767-2733
Practice Address - Fax:256-767-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13592085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552219Medicare ID - Type Unspecified